BMJ Open Quality最新文献

{"title":"Effectiveness of nurse-led care in patients with rheumatoid arthritis: a systematic review and meta-analysis.","authors":"Lin Yang, Peng Xiang, Guifang Pi, Ting Wen, Li Liu, Dan Liu","doi":"10.1136/bmjoq-2024-003037","DOIUrl":"10.1136/bmjoq-2024-003037","url":null,"abstract":"<p><strong>Objectives: </strong>This study sought to assess the effectiveness of nurse-led care (NLC) in patients with rheumatoid arthritis (RA).</p><p><strong>Methods: </strong>We conducted a comprehensive search of the Cochrane Library, Web of Science, PubMed, Embase, CINAHL, ClinicalTrials.gov databases and the references from relevant literature published prior to May 2023. Two independent reviewers assessed the studies using population/intervention/comparison/outcome/study criteria, and quantitative tools were used to gauge the methodological quality of the included studies. Independent quality assessments were carried out using the Cochrane Collaboration's risk-of-bias tool. Effect sizes were determined using mean difference (MD) or standardised mean difference (SMD) with corresponding 95% CIs.</p><p><strong>Results: </strong>Ultimately, 14 articles were included, encompassing a total of 3369 RA patients. NLC exhibited significant advantages in the primary outcome, disease activity (MD =-0.09, 95% CI (-0.17 to -0.01)), and the secondary outcome, self-efficacy (MD=0.40, 95% CI (0.03, 0.77)). In subgroup analysis, NLC was more effective in reducing disease activity compared with usual care (MD=-0.15, 95% CI (-0.26 to -0.04)), and there was no significant difference in disease activity reduction between NLC and rheumatologist-led care (MD=-0.02, 95% CI (-0.14, 0.10)). In terms of self-efficacy, no significant difference was observed between NLC and usual care (SMD=0.56, 95% CI (-0.09, 1.21)) or between NLC and rheumatologist-led care (SMD=0.20, 95% CI (-0.19, 0.59). When comparing other secondary outcomes (pain, satisfaction, quality of life, fatigue, stiffness, physical function and psychological status), the effectiveness of NLC for RA patients was similar to that of the control group, with no statistically significant differences.</p><p><strong>Conclusions: </strong>NLC proves highly effective in managing RA patients, surpassing usual care and equating to rheumatologist-led care in primary and some secondary outcomes. It may be feasible to allow nurses to participate in the disease management of some RA patients instead of doctors.</p><p><strong>Prospero registration number: </strong>CRD42022362071.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"14 1","pages":""},"PeriodicalIF":1.3,"publicationDate":"2025-01-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11751805/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142925993","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Effect of providing at-home opioid disposal kits at discharge after an orthopaedic surgery.","authors":"Eric Shan, Ruiying Xiong, Michael Katzman, Zarina Ali, Daniel Lee, M Kit Delgado, Anish Agarwal","doi":"10.1136/bmjoq-2024-003040","DOIUrl":"10.1136/bmjoq-2024-003040","url":null,"abstract":"<p><p>Prescription opioids after surgery may pose a risk if left unused. However, prescribers rely on their best judgement in determining how much their patients need, often resulting in over-prescription of these medications. Opioid disposal is a strategy to reduce the risk of persistent use or misuse of opioids. At-home disposal kits allow patients to safely dispose of leftover opioids. In this study, we assess the impact of opioid disposal kits on disposal rates after orthopedic surgery. In a difference-in-differences study of 1,321 eligible patients, disposal kits were associated with a 10.6 percentage point increase (95% CI: -3.5% to 24.7%) in disposal rates as well as a 10.5 percentage point increase (95% CI: 0.2% to 20.9%) in the fraction of opioids disposed. We build on prior research and identify that providing surgery patients with an opioid disposal kit at the time of discharge increases their self-disposal rates.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"14 1","pages":""},"PeriodicalIF":1.3,"publicationDate":"2025-01-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11751830/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142925975","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Prehospital video triage of suspected stroke patients in Greater Manchester: pilot project report.","authors":"Ibrahim Alghamdi, Lisa Brunton, Christopher Ashton, David A Jenkins, Adrian R Parry-Jones","doi":"10.1136/bmjoq-2024-002954","DOIUrl":"10.1136/bmjoq-2024-002954","url":null,"abstract":"<p><strong>Introduction: </strong>Stroke is a leading cause of mortality and morbidity, demanding prompt and accurate identification. However, prehospital diagnosis is challenging, with up to 50% of suspected strokes having other diagnoses. A prehospital video triage (PHVT) system was piloted in Greater Manchester to improve prehospital diagnostic accuracy and appropriate conveyance decisions.</p><p><strong>Method: </strong>A service evaluation of a PHVT pilot was conducted to assess PHVT efficacy and identify facilitators and barriers. The pilot (October-December 2022) was a collaboration between the North West Ambulance Service, Greater Manchester Neurorehabilitation and Integrated Stroke Delivery Network and stroke clinicians at Salford Royal Hospital. The service evaluation was mixed methods, including qualitative semistructured interviews with stroke clinicians, paramedics and patients (and/or caregivers). Interviews were analysed using a thematic approach.</p><p><strong>Results: </strong>Out of 46 PHVT calls during the pilot, eight (18%) were diverted to local emergency department, 1 (2%) was left at their usual residence and 37 (80%) were transported to Salford Royal Hospital. Final diagnosis for PHVT patients was stroke in 15 (33%) of cases, non-stroke in 20 (43%) and transient ischaemic attack in 11 (24%).Patients/caregivers found PHVT beneficial in directing them to appropriate hospitals and streamlining admission and treatment. However, some reported delays as a result. Clinicians expressed mixed opinions regarding PHVT's utility. Paramedics found PHVT improved confidence in managing stroke patients. Hospital clinicians believed it provided valuable prearrival patient information, enhancing preparation. Others found PHVT less effective due to on-scene delays, challenges conducting comprehensive assessments over video and inability to identify all non-stroke cases.</p><p><strong>Conclusion: </strong>PHVT was viewed favourably by most patients for enhancing the care quality. Paramedics and hospital clinicians acknowledge PHVT's support in making appropriate conveyance decisions and improving the preparation process before the patient's arrival. Participants, however, suggested prearrival registration, 24-hour availability and clinicians' buy-in for a more effective future rollout.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"14 1","pages":""},"PeriodicalIF":1.3,"publicationDate":"2025-01-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11751970/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142925922","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Novel pathways for headache via neurology same day emergency care: admission avoidance, prevention of lumbar punctures and reduced length of stay in hospital.","authors":"William Bierrum, Jonathan Ian Spencer, Roberto Macarimban, Ayala Shirazi, Agampodi-Umanda Dethabrew, Isaiah See, Alun Marc Henry, Anne Schlattl, Ali-Jesus Alim-Marvasti, Michelle Balaratnam, Arvind Chandratheva, Tim Baruah, Robert Simister, Salman Haider","doi":"10.1136/bmjoq-2024-003036","DOIUrl":"10.1136/bmjoq-2024-003036","url":null,"abstract":"<p><p>There are various models for acute neurology services in the UK, with considerable variation in practice. Patients are often admitted unnecessarily for neurology review, leading to delay in diagnosis and treatment. Alternative models, such as the Neurology Same Day Emergency Care service (Neuro-SDEC) at University College London Hospital provide a pathway that can prevent admissions and streamline patient care. Headache is one of the commonest presenting symptoms in acute neurology.This study compared the impact of Neuro-SDEC on the care for patients presenting with headache against the standard pathway.A prospective audit was undertaken from November - December 2023 to evaluate all appropriate patients seen by the Neuro-SDEC service or admitted to the ward. For Neuro-SDEC patients, each case was reviewed to see whether an admission, lumbar puncture or neurology outpatient referral was avoided. For admitted patients, length of inpatient stay, time to neurology review and discharge diagnosis was recorded.Fifty-one patients were seen by Neuro-SDEC, twenty-five of whom would have been admitted to hospital on the standard pathway. Thirty general neurology outpatient clinic referrals were prevented and 5 patients avoided a lumbar puncture. In 45% of cases, the working diagnosis changed after the patient was seen by the Neuro-SDEC team. There were seven admitted patients not seen by the service with a combined length of stay of 17 bed days. The average wait time for inpatient neurology review was 42 hours. 3 admitted patients underwent a lumbar puncture. 2 patients were referred on to neuro-SDEC to enable an earlier discharge from hospital. Migraine was the most common final diagnosis in both groups.This study highlights that Neuro-SDEC is effective at reducing hospital admissions, as well as unnecessary tests and referrals to generalneurology outpatients. For admitted patients, the service enabled earlier discharge from hospital and reduced length of stay.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"13 4","pages":""},"PeriodicalIF":1.3,"publicationDate":"2024-12-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11751804/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142909247","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Barriers to medication administration error reporting in a tertiary hospital in Lebanon.","authors":"Diala Mehanna, Najwa El Gerges, Marianne Chalhoub, Remy Daou","doi":"10.1136/bmjoq-2024-002994","DOIUrl":"10.1136/bmjoq-2024-002994","url":null,"abstract":"<p><strong>Objective: </strong>The aim of this study is to identify the key barriers that prevent medication administration errors (MAEs) from being reported by nurses in Lebanese hospitals.</p><p><strong>Methods: </strong>A quantitative cross-sectional study was conducted at Hotel-Dieu de France Hospital using a self-administered questionnaire. A total of 275 responses were recorded and analysed using the IBM SPSS software V.23.0.</p><p><strong>Results: </strong>Our study showed that 'Fear' and 'Administrative response' present the two main types of barriers to MAE reporting with a frequency of 62.9% and 60.7%, respectively, with more than half of our nurses confirming it (52.7%). The significant administrative barriers are: No positive feedback if medications were given correctly, too much emphasis being placed on MAE and the focus by the nursing administration on the individual rather than looking at the systems as a potential cause of the MAE whereas the significant fear barriers are the chances of suing the nurse if MAE is reported, the fear of adverse consequences of MAE reporting, the blame of nurses if something happens to the patient as a result of the MAE. No significant association was found between the barriers and demographic factors such as age, gender, experience and attending the training and orientation programmes.</p><p><strong>Conclusion: </strong>The findings highlight the need for targeted strategies to address these types of barriers. Anonymous error reporting, fostering a culture of transparency and adopting a non-punitive reporting system are approaches that can be implemented for optimal performance improvement, enhanced safety and healthcare quality and reduced wasting of the hospitals' financial resources.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"13 4","pages":""},"PeriodicalIF":1.3,"publicationDate":"2024-12-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11752005/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142963285","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Releasing time to care: a quality improvement project aimed to increase direct rehabilitation time in a Stroke Rehabilitation Centre.","authors":"Dolores Macchiavello, Jennifer Blackhouse, Jennifer Clark, Claire Haddock, James Hinder, Benjamin Jelley, Amy Joyce, Kate Matchett, Eden Morris, Carys Moss, Chris Rees, Alun Walters, Susan White","doi":"10.1136/bmjoq-2024-003043","DOIUrl":"10.1136/bmjoq-2024-003043","url":null,"abstract":"<p><p>Stroke is a leading cause of disability among adults, and any treatment that improves functional outcome, like higher intensity of rehabilitation therapy, can significantly reduce its financial burden. Clinicians on a stroke rehabilitation ward are expected to track and nationally report on rehabilitation time to contribute to the Sentinel Stroke National Audit Programme (SSNAP), a process that was manual, paper-based, time-consuming and redundant, which in turn impacted on a reduction in clinical time to provide stroke rehabilitation. We aimed to release 20% of clinical time by reducing inefficiencies within their time management and reporting process, ensuring that clinicians had more time available for direct patient care. To do so, we developed a tool to gather and analyse SSNAP-specific data and use Kanban cards to make weekly actions visible to reduce miscommunication. As a result, the whole occupational therapists team gained 7.5 hours a month (25% of released time, 12 extra additional therapy sessions available) when improving their data gathering and analysis process. A specialist physiotherapist saw a 2 hour a month gained and 4 hours a month gained for a Physiotherapist. Dietitians also saved 3 hours a month by not having to duplicate information. This process is part of a key organisational requirement for clinical teams working with stroke patients admitted to hospital and by addressing some inefficiencies, we were able to impact on direct patient care.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"13 4","pages":""},"PeriodicalIF":1.3,"publicationDate":"2024-12-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11751994/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142963471","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Value-based healthcare for social insurance medicine: key enablers for adoption in practice.","authors":"Marije E Hagendijk, Nina Zipfel, Philip J Van Der Wees, Marijke Melles, Jan L Hoving, Sylvia J van der Burg-Vermeulen","doi":"10.1136/bmjoq-2024-002878","DOIUrl":"10.1136/bmjoq-2024-002878","url":null,"abstract":"<p><strong>Background: </strong>Driven by rising retirement age and increasing prevalence of chronic diseases impacting work participation, there is an increasing need for quality and efficiency improvement in social insurance medicine (SIM). SIM provides guidance to individuals facing long-term work disability, assess their functional abilities and eligibility for long-term disability benefits. Value-based healthcare (VBHC) targets quality and efficiency improvements in healthcare by placing a priority on improving patient value. So far, VBHC has been introduced with fundamental principles and essential components for its adoption in curative care. Hence, there is room for debate on what are key enablers for the adoption of value-based SIM.</p><p><strong>Purpose: </strong>The study aims to explore key enablers for the adoption of VBHC in the practice of SIM.</p><p><strong>Methods: </strong>In this exploratory qualitative study, participants consisted of 15 professionals with expertise either in SIM (n=10) or with expertise in the adoption of VBHC in the curative care sector (n=5). Each participant took part in both a semistructured individual interview and a focus group interview. Thematic coding was employed to analyse the data.</p><p><strong>Results: </strong>Seven key enablers were identified: (1) investigate the meaning and implementation constraints of value in SIM, (2) integrate SIM into work-focused care networks, (3) explore the need and feasibility for specialisation based on functional problems, (4) identify the most important work outcomes for the patient, (5) identify proxy indicators for cost drivers, (6) identify value-driven financial incentives and (7) develop an information technology system to exchange data.</p><p><strong>Conclusions: </strong>This paper provides understanding of what is needed to adopt value-based SIM. Future research should delve deeper into these seven key enablers to facilitate the adoption of VBHC, and thereby promote value creation in the practice of SIM.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"13 4","pages":""},"PeriodicalIF":1.3,"publicationDate":"2024-12-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11752058/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142963711","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Using the communication technique of Clean Language in healthcare: an exploratory survey.","authors":"Saskie Dorman, Judy Rees","doi":"10.1136/bmjoq-2024-003102","DOIUrl":"10.1136/bmjoq-2024-003102","url":null,"abstract":"<p><p>Communication is fundamental to effective healthcare. Misunderstandings can increase distress, risks and costs. Clean Language is a precision questioning technique-with specific Clean Language questions which minimise assumptions and bias. It is used in a variety of contexts but is under-researched in healthcare. An exploratory online survey was undertaken to develop an understanding of who uses Clean Language in healthcare, in what kind of roles, settings, contexts and what impacts they identify. 32 people responded, of whom 23 reported using Clean Language in a range of contexts, individually and in groups; 21 people had received training in Clean Language. Participants worked in a wide range of roles, specialties and settings, both clinical and non-clinical, and described Clean Language enabling engagement and encouragement; confidence, knowledge and power; surfacing and handling emotion and conflict in a safe way; clarity, depth, understanding and insights. Some respondents noted that Clean Language is not always intuitive and takes practice but can become natural and enjoyable to use. Communication skills training could include Clean Language questions as one way to enhance understanding. Further exploration of the impact of Clean Language, including from the perspective of patients and families, is warranted.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"13 4","pages":""},"PeriodicalIF":1.3,"publicationDate":"2024-12-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11752020/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142963710","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Development and evaluation of a quality improvement educational video on joint contractures for care home staff.","authors":"Hina Tariq, Joel Dunn, Samantha Forrester, Kathryn Collins, Sam Porter","doi":"10.1136/bmjoq-2024-002923","DOIUrl":"10.1136/bmjoq-2024-002923","url":null,"abstract":"<p><strong>Background: </strong>Contractures are a debilitating problem for individuals living in long-term care settings. However, there is a lack of education and training among the care staff regarding the identification of risk factors related to contractures and the preventive strategies that can decrease their development or progression. Addressing this knowledge gap has the potential to improve the quality of care provided to residents in care homes.The objective of this quality improvement (QI) project was to investigate the impact of a newly developed educational video on the awareness, knowledge and understanding of contractures among the care staff.</p><p><strong>Methods: </strong>This QI project involved two sequential Plan-Do-Study-Act cycles and employed a pre and post-test design to evaluate the impact of the contracture educational video. Primary outcomes were assessed using paper surveys to capture prevideo and postvideo levels of knowledge and understanding of contractures. Furthermore, both verbal and written feedback from participants were gathered to identify areas of strengths and improvement.</p><p><strong>Results: </strong>Baseline data revealed that about 56% of the care staff lacked knowledge and understanding of contractures with another 33% reporting possessing only basic knowledge. Following the video intervention, percentage of care staff who reported good knowledge and understanding increased to 67% while 22% reported basic knowledge and understanding of contractures. The care staff suggested changes to the video to improve accessibility of the information, this was incorporated in the refilming of the video.</p><p><strong>Conclusion: </strong>This QI project demonstrated that the introduction of a contracture educational video is a feasible and positively received method of enhancing awareness, knowledge and understanding of contractures among care staff. Educating care staff about the risk factors and prevention strategies for contractures will potentially improve their ability to identify the risk of contractures and help prevent their occurrence, ultimately enhancing the quality of care of the residents.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"13 4","pages":""},"PeriodicalIF":1.3,"publicationDate":"2024-12-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11683971/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142891929","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Changing the culture: increasing captured intraoperative anaesthesia-related safety events through targeted interventions.","authors":"Joseph William McSoley, David Winthrop Buck, Abby V Winterberg","doi":"10.1136/bmjoq-2024-002787","DOIUrl":"10.1136/bmjoq-2024-002787","url":null,"abstract":"<p><strong>Background: </strong>There is an under-reporting of anaesthesia-related safety events.¹⁰ Incident-capturing systems (ICSs) are essential for patient safety monitoring, identifying risks and ongoing opportunities for improvement. After a literature review and assessment of our current ICSs, we concluded that our institution lacked a reliable anaesthesia-specific ICS system, leading to under-reporting of anaesthesia-related safety events.</p><p><strong>Methods: </strong>We conducted a quality improvement initiative to help increase perioperative safety event reporting by anaesthesiologists, fellows and certified registered nurse anaesthetists. We analysed all anaesthesia-related perioperative safety events from July 2019 to December 2020 to determine a baseline rate of safety events captured. We conducted a simplified failure-mode effects analysis and designed a key driver diagram to guide our initiative. Based on these, we designed and implemented seven interventions aimed at increasing anaesthesia-related perioperative safety event reporting. We then reviewed perioperative safety events captured from January 2021 to February 2023 and compared the safety event capture rate to baseline.</p><p><strong>Results: </strong>Over 10 months, we trialled and implemented multiple interventions aimed at increasing perioperative anaesthesia-related safety event capture, including re-education, strategic placement of report forms, education of anaesthesia and non-anaesthesia personnel, celebration of events captured, promotion of a safe-capture culture where reporting was not seen as punitive and the transition to an online anaesthesia ICS. Over 25 months, we demonstrated a sustained increase in event reporting from a baseline of 1.9 incidents captured per week (average of 1000 cases performed weekly) to 19 events captured per week postinterventions.</p><p><strong>Conclusions: </strong>Increasing event reporting required a multifaceted approach-ongoing attention to reporting barriers and developing targeted interventions promoting sustained reporting. Education on the importance of reporting, creating a reliable electronic ICS, creating a non-punitive culture and continuing to promote a safety culture contributed to system improvement.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"13 4","pages":""},"PeriodicalIF":1.3,"publicationDate":"2024-12-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11683889/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142891621","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}